Provider Demographics
NPI:1588061725
Name:WOGEN, BRYAN N (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:N
Last Name:WOGEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E CHEYENNE MTN BLVD STE 199
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-1528
Mailing Address - Country:US
Mailing Address - Phone:719-398-1415
Mailing Address - Fax:719-487-0005
Practice Address - Street 1:7610 N UNION BLVD STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3800
Practice Address - Country:US
Practice Address - Phone:719-434-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40533824Medicaid